Bipolar disorder manic episode

Friedman, E., Hoau Yan, W., Levinson, D. et al. Altered platelet protein kinase C activity in bipolar affective disorder, manic episode. Biol Psych. 33 520-525,1993. 

Lithium is the simplest therapeutic agent for the treatment of depression and has been used for over 100 years—lithium carbonate and citrate were described in the British Pharmacopoeia of 1885. Lithium therapy went through periods when it was in common use, and periods when it was discouraged. Finally, in 1949, J.J.F. Cade reported that lithium carbonate could reverse the symptoms of patients with bipolar disorder (manic-depression), a chronic disorder that affects between 1% and 2% of the population. The disease is characterized by episodic periods of elevated or depressed mood, severely reduces the patients quality of life and dramatically increases their likelihood of committing suicide. Today, it is the standard treatment, often combined with other drugs, for bipolar disorder and is prescribed in over 50% of bipolar disorder patients. It has clearly been shown to reduce the risk of suicide in mood disorder patients, and its socioeconomic impact is considerable—it is estimated to have saved around 9 billion in the USA alone in 1881. 

Bipolar disorder (manic-depressive illness) represents one of the most dramatic presentations in all of medicine and simultaneously poses one of the more difficult therapeutic challenges. It is characterized by mania or hypomania, alternating irregularly or intermingling with episodes of depression however, a small group (approximately 1%) may only experience recurrent manic episodes (i.e., unipolar mania). The estimated risk of developing a bipolar disorder is 0.5% to 1%, and the incidence of new cases per year is in the range of 0.01 % for men and 0.01 % to 0.03% for women (1). Bipolar spectrum can be conceived of as a continuum of more to less severe clinical presentations ... 

In a retrospective chart review of 167 patients with a variety of anxiety disorders, excluding patients with evidence of current or previous mood disorder, manic episodes were recorded in five patients, a rate of 3% (20). While this might suggest a clear effect of SSRIs to induce mania, two of the patients were taking clomipramine, a tricyclic antidepressant, albeit a potent serotonin reuptake inhibitor. In addition, all the affected patients had additional diagnoses of histrionic or borderline personality disorder, known to be associated with mood instability. It is still therefore plausible that SSRIs cause mania only in patients with an underlying predisposition, although this may be more subtle than a personal or family history of bipolar illness. 

The natural course of bipolar disorder is episodic and highly recurrent. Initially, it can present with one or more episodes of depression before the first frankly hypomanic or manic episode occurs. In many cases, manic and hypomanic episodes may precede or follow a depressive episode. Episodes usually last several months and may resolve spontaneously, without treatment. Recurrences every 2 years or so are not uncommon, and over time the frequency and intensity of episodes may actually worsen. In general, there is great variability in its course from patient to patient. A graphic rendition of the median life course of affective illness (based on the life course of 82 patients), including episodes of mania and depression, treatments, and hospitalizations, is illustrated in Figure 3.3. 

Bipolar disorder manic and depressive episodes (see chapter 6)... 

Bipolar disorder (manic-depressive illness) is one of the most common of the severe chronic psychiatric disorders. The cyclic mood disorder is characterized by recurrent fluctuations in mood, energy, and behavior encompassing the extremes of human experiences.Bipolar disorder differs from recurrent major depression (or unipolar depression) in that a manic, hypomanic, or mixed episode occurs during the course of the illness. Bipolar disorder is a lifelong illness with a variable course and requires both nonpharmacologic and pharmacologic treatments for mood stabilization. ... 

Treatment of Manic—Depressive Illness. Siace the 1960s, lithium carbonate [10377-37-4] and other lithium salts have represented the standard treatment of mild-to-moderate manic-depressive disorders (175). It is effective ia about 60—80% of all acute manic episodes within one to three weeks of adrninistration. Lithium ions can reduce the frequency of manic or depressive episodes ia bipolar patients providing a mood-stabilising effect. Patients ate maintained on low, stabilising doses of lithium salts indefinitely as a prophylaxis. However, the therapeutic iadex is low, thus requiring monitoring of semm concentration. Adverse effects iaclude tremor, diarrhea, problems with eyes (adaptation to darkness), hypothyroidism, and cardiac problems (bradycardia—tachycardia syndrome). 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Bipolar disorder or manic depressive illness, refers to a severe mental illness characterized by recurring episodes of mania and depression. 

Although lithium is not a true antipsychotic drug, it is considered with the antipsychotics because of its use in regulating the severe fluctuations of the manic phase of bipolar disorder (a psychiatric disorder characterized by severe mood swings of extreme hyperactivity to depression). During the manic phase, the person experiences altered thought processes, which can lead to bizarre delusions. The drug diminishes the frequency and intensity of hyperactive (manic) episodes. 

Depression often follows a manic episode (bipolar I disorder), but in other cases the main disorder presents as depressive episodes which are followed by or sometimes... 

Major depressive episodes also occur in the context of bipolar disorder. The key difference is that persons with bipolar disorder also experience manic, hypomanic, and/or mixed episodes (see Chap. 36) during the course of their illness, whereas persons with MDD experience only major depressive episodes.3... 

Recognize the symptoms of a manic episode and depressive episode in patients with bipolar disorder. 

Bipolar disorder is a mood disorder characterized by one or more episodes of mania or hypomania, often with a history of one or more major depressive episodes.1 It is a chronic illness with a course characterized by relapses and improvements or remissions. Mood episodes can be manic, depressed, or mixed. They can be separated by long periods of stability or can cycle... 

Bipolar disorders have been categorized into bipolar I disorder, bipolar II disorder, and bipolar disorder, not otherwise specified (NOS). Bipolar I disorder is characterized by one or more manic or mixed mood episodes. Bipolar II disorder is characterized by one or more major depressive episodes and at least one hypomanic episode. Hypomania is an abnormally and persistently elevated, expansive, or irritable mood, but not of sufficient severity to cause significant impairment in social or occupational function and does not require hospitalization. Most epidemiologic studies have looked at bipolar disorder of all types (bipolar I and bipolar II), or the bipolar spectrum, which includes all clinical conditions thought to be closely related to bipolar disorder. The lifetime prevalence of bipolar I disorder is estimated to be between 0.3% and 2.4%. The lifetime prevalence of bipolar II disorder ranges from 0.2% to 5%. When including the bipolar spectrum, the lifetime prevalence is between 3% and 6.5%.1... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

The distinguishing feature of bipolar II disorder is depression with past hypomanic episodes that often are not recalled by the individual as being unusual. Irritability and anger episodes are also common. Collateral information is essential to obtain the entire history (i.e., there cannot have been a prior full manic episode).1,14... 

Treatment algorithms for manic and depressive episodes of bipolar disorder are included in Table 36-2. 

Interpersonal, family, or group therapy with a licensed psychiatric nurse practitioner/clinical nurse specialist, psychologist, social worker, or counselor assists individuals with bipolar disorder to establish and maintain a daily routine and sleep schedule and to improve interpersonal relationships.3,20 These therapies may help treat and protect against manic episodes. 

Zhang, H. Y., Shu, L., Li, H. F. et al. (2006). Risperidone versus haloperidol in treatment of acute manic episodes of bipolar 1 disorder a randomized double-blind controlled multicenter study. Journal of Chinese Psychiatry, 39(1), 33-7. 

Two or more major depressive episodes Manic episode major depressive or mixed episode Major depressive episode + hypomanic episode Chronic subsyndromal depressive episodes Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents) Mood states do not meet criteria for any specific bipolar disorder... 

For bipolar I disorder, 90% of individuals who experience a manic episode later have multiple recurrent major depressive, manic, hypomanic, or mixed episodes alternating with a normal mood state. 

Divalproex sodium (sodium valproate) is now the most prescribed mood stabilizer in the United States. It is FDA approved only for the treatment of acute manic or mixed episodes, but it is often used as maintenance monotherapy for bipolar disorder. 

Aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone are FDA approved for the treatment of acute manic episodes in bipolar I disorder. 

Valproate is as effective as lithium and olanzapine for pure mania, and it can be more effective than lithium for rapid cycling, mixed states, and bipolar disorder with substance abuse. It reduces the frequency of recurrent manic, depressive, and mixed episodes. 

Example 3 Is Bipolar I Disorder, Single Manic Episode (296.0x) a Taxon ... 

I ve been diagnosed with bipolar disorder. I just went through a depression, but now I m feeling better. The problem with bipolar is that when you are treated for depression it can set off a manic episode. I have to be really careful. I ve been hospitalized four times with manic episodes. I was told by a doctor that my bipolar disorder is an imbalance in brain chemistry caused by chemical exposures. 

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